Chapter 10 Patient Assessment Knowledge Objectives

Discuss the steps used to identify and subsequently treat life threatening conditions that endanger a patient during an emergency

DCAP-BTLS (deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling)

List the steps EMTs should follow during the primary assessment of a trauma patient, including examples of abnormal signs and appropriate related action

DCAP-BTLS the following by order Head Neck Chest Abdomen Pelvis Four Extremities Back & Buttocks

List normal blood pressure ranges for adults, children, and infants

Adult: 90-130 Children: 88-115 Infant: 85-104

Explain the process for determining the priority of patient care and transport at an emergency scene and include examples of conditions that necessitate immediate transport

After completing assessment you will find indications for rapid transport i.e unresponsiveness, uncontrolled breathing pale skin, severe pain, poor general impression.....

Explain situations in which patients may receive a focused assessment, including examples by body system of what each focused assessment should include based on a patient's chief complaint.

An assessment on a responsive patient based on the chief complaint ~Respiratory: Rate, Rhythm, Quality, Depth ~Cardiovascular: Pulse Rate, Pulse Rhythm, Blood Pressure ~Neurological: AVPU, Glasgow Scale ~Pupils: Pupils Equal And Round Regular Size react to Light (PERRL) ~Neurovascular: Determine sensory & Motor Response ~Anatomic Regions: Head, Neck, Cervical Spine ~Chest Abdomen, Pelvis, Extremities: Abnormalities

Describe the assessment of airway status in patients who are both responsive and unresponsive, including examples of possible signs and causes of airway obstruction in each case as well as the appropriate EMT response.

Assess: patency and adequacy Responsive: talking or crying means patent, listen to how pts speak to determine adequacy; stop and clear pts airway if there is a problem Unresponsive: assess patency (trauma = jaw thrust maneuver, no trauma = head tilt-chin lift)Signs of obstruction (unconscious): Obvious trauma, blood, or other obstruction; Noisy breathing, such as snoring, bubbling, gurgling, crowing, stridor, or other abnormal sounds; Extremely shallow or absent breathing

Describe the assessment of a patients breathing status, including the key information EMTs must obtain during this process and the care required for patients who have adequate and inadequate breathing.

Assessment Conscious pt :Speech: Easy speech indicates non-labored breathing, whereas two/three-word dyspnea indicates labored breathing Effort: Presence of retractions, use of accessory muscles, nasal flaring, or two- to three-word dyspnea indicates labored breathing Posture: tripod position or sniffing position (more commonly seen in children) indicates labored breathing Care Patient's who are not breathing or are breathing too slow/too shallow: Positive Pressure Ventilations (PPV)

List the minimum standard precautions that should be followed and personal protective equipment (PPE) that should be worn at an emergency scene, including examples of when additional precautions would be appropriate.

Assume all blood, bodily fluids, nonintact skin, and mucous membranes pose a threat of exposure to communicable disease minimum: gloves additional: glasses, mask

Explain the importance of assessing a patient's level of consciousness (LOC) to determine altered mental status, and include examples of different methods used to assess alertness, responsiveness, and orientation.

LOC gives insight about neurologic and physiologic status Consciousness: - unconscious - conscious w/ altered LOC - conscious w/ unaltered LOC Responsiveness: APVU (awake/alert, verbal stimuli, pain, unconscious) Orientation (mental status):Person, Place, Time, Event

Discuss some of the possible environmental, chemical, and biologic hazards that may be present at an emergency scene, ways to recognize them, and precautions to protect personal safety.

Be aware of the environment: - location (in/outdoors, public/private) - weather and its effect on terrain - water, mud, ice - uneven/unstable surfaces- sharp metal, broken glass- road and traffic hazards - violence- fire, explosions - Chemical: hazardous materials, carbon monoxide - Electrical: downed power lines - Biological: biohazards (blood, body fluids), infectious diseases, airborne pathogens Precautions:- Wear proper BSI and PPE - Roadway: high-visibility safety vest, traffic markers (cones, flares, signs), traffic personnel, strategic positioning of vehicles - Call for additional resources - Any actions to protect yourself should also be done for the pt whenever possible

List the signs of respiratory distress and respiratory failure

Behavioral Distress: Agitation, anxiety, restlessness Failure: Lethargy, difficult to rouse Respirations Distress: Stridor, wheezing Failure: Tachypnea with periods of bradypnea or agonal respirations Thorax Distress: Accessory muscle use; intercostal reactions, neck muscle use Failure: Inadequate chest rise/poor excursion Heart Rate Distress: Tachycardia Failure: Bradycardia Other Distress: Nasal flaring, seesaw breathing, head bobbing Failure: Diminished muscle tone

Describe how to determine the mechanism of injury (MOI) or nature of illness (NOI) at an emergency and the importance of differentiating trauma patients from medical patients.

MOI (trauma): classified according to type/amount of force, duration, location on body; Blunt vs penetrating trauma, fragile/easily injured areas of body, unseen injuries, potential for infection NOI (medical): general type of illness pt is experiencing; CC Determination: search for clues; talk with the pt, family, or bystanders; meds, substances, unsanitary conditions, sounds, smells. Also: Be aware of scenes with multiple pts exhibiting similar signs/symptoms (may indicate scene is unsafe! ex: carbon monoxide poisoning) Importance: direct assessment and care of pt; determine appropriate equipment/resources; may be ambiguous (consider pt unconscious at bottom of ladder: did they fall, hit head, and lose consciousness [trauma] or did a medical problem cause of loc and fall?)

Describe the purpose of a secondary assessment and a physical exam; include how to determine which aspects of the physical exam to use, and the step

Secondary exam is a head-to-toe examination and assessment that focuses on a certain area determined by chief complaint. Inspection (looking for abnormalities, Palpation (feeling for abnormalities), Auscultation (listening to sounds)

OPQRST

Signs and symptoms: What signs and symptoms occurred at onset of incident? Does the pt report pain? Allergies: Is the pt allergic to anything/what was the reaction. If none, write NKA (no known allergies) Medications: What medication/dosage is pt prescribed?What prescription, OTC, or herbal medication has PT taken in last twelve hours? Pertinent past medical history: Does PT have any history of medical, surgical, or trauma occurrences? Has PT had a recent illness or injury, fall, or blow to the head? Any important family history that should be known? Last oral intake (eat or drink):When/What did the PT last eat or drinK? Did the PT take any drugs/alcohol? Has there been any other oral intake in the last 4hrs? Events leading up to the injury or illness: What are the key events that led up to this incident? What was the PT doing when this illness started? What was the patient doing when this injury happened?

Discuss the steps EMTs should take to survey a scene for signs of violence and to protect themselves and bystanders from real or potential danger.

Situations at risk for violence: - violent pts - distraught family - angry bystanders - gangs - unruly crowds Request assistance of law enforcement and move to a safe location. Scan for weapons (both typical and any object that could act as a potential weapon). Place self between pt and potential weapon to prevent access. Remain aware of the scene and any changes.

Describe the assessment of a patient's skin color, temperature, and condition, including examples of both normal and abnormal findings and the information this provides related to the patient's status

Skin Color: Normal: Pink (look at nailbeds and palms for darker POCs) indicates normal perfusion Abnormal: Pale/white/ashen/gray: poor peripheral circulation Blue: hypoxia Flushed/red: High BP Yellowy: Jaundice Skin Temperature: Abnormal: Hot: Fever, sunburn, hyperthermia Cold: Early shock, mild shock, hypo perfusion Skin moisture: Normal: Dry Skin Abnormal: Diaphoretic: Shock CRT (Capillary Refill): Normal: 2 second refill Abnormal: hypothermia, frostbite, vasoconstrictions

Discuss the importance of protecting a trauma patient's spine and identifying fractured extremities during patient packaging for transport

Spinal injuries can be made worse if you neglect to assess and treat them before moving the patient.

Discuss the process of assessing for and methods for controlling external bleeding

Spurting flow indicates arterial bleeding, Steady flow indicates large vein bleeding. Apply direct pressure to help coagulate

Explain the importance of performing a reassessment of the patient and the steps in this process

Steps: 1. Repeat the Primary Assessment 2. Reassess Vital Signs 3. Reassess Chief Complaint 4. Recheck Interventions Most importantly, recheck the ABC's. Additionally, bandages, spinal immobilization, bleeding management, etc. 5. Identify and treat changes in the patient's condition. If conditions are improving, continue what you were doing. If deteriorating, modify. Most importantly, DOCUMENT any changes, whether positive or negative 6. Reassess patient Unstable patients should be reassessed every 5 minutes, stable patients should be reassessed every 15 minutes

Explain how the different causes and presentations of emergencies will affect EMT's perform each step of the patient assessment process.

The steps represent a logical approach to evaluation but the order should be dictated by the PTs chief complaint MOI/NOI. It may be necessary to re-order or prioritize the steps after scene size up based on your findings.

Explain why it is important for EMTs to identify the total number of patients at an emergency scene and how this evaluation relates to determining the need for additional or specialized resources, implementation of the incident command system (ICS), and triage.

You can only transport one pt at a time for multiple pts use ICS, identify # of pts, and begin triage ICS: system to manage a variety of emergency scenes (resources from other entities, ex: FD, PD, ALS, air medical support, additional ambulances, CPS) Triage: prioritizing multiple pts based on severity of condition

Explain the process of forming a general impression of a patient as part of primary assessment and the reasons why this step is critical to patient management.

general impression used to determine priority of care; observe demographics, level of distress, appearance, LOC, and ABCs Observe behavior and answers to questions Determine if stable, stable but potentially unstable, or unstable

Describe the principal goals of the primary assessment process, including how to identify and treat life threats and determine if immediate transport is required.

goal: identify & begin treatment of imminent life threats assess: significant trauma, bleeding, LOC, ABCs significant trauma, AMS, problems with A, B or C warrant immediate transport risk for sudden death: airway obstruction, respiratory failure, respiratory arrest, shock, severe bleeding, cardiac arrest

Discuss different challenges EMTs may face when taking a patient history on sensitive topics and strategies they can be used to facilitate each situation

~Alcohol & Drugs: Information may be unreliable, stress confidentiality ~Physical abuse or Violence: Must be reported to law enforcement, look for signs be observant, nonjudgmental ~Sexual History: may be limited, very personal due to bizarre practices, uncomfortable sharing

Explain the variations required to obtain a pulse in infant and child patients compared with adult patients

~Older than 1 year palpate Radial pulse (WRIST) ~Unresponsive older than 1 Palpate Carotid (NECK) ~Under 1 year palpate brachial pulse (INSIDE UPPER ARM)

Key components of history taking

1. Investigate Chief Complaint: OPQRST (onset, provocation, quality, radiation, severity, and time) and Pertinent Negatives 2. SAMPLE

Identify the components of the patient assessment process

1. Scene size up 2. primary assessment 3. history taking 4. secondary assessment 5. reassessment

Describe the assessment of a patient's circulatory status and appropriate management depending on the patient's status

Evaluation: 1. Pulse: Radial for responsive, carotid for unresponsive, brachial for baby 2. Skin: Color, temperature, moisture 3. Capillary Refill Time 4. Assess and control bleeding. Appropriate management: No pulse in unresponsive patient: CPR + AED Pulse but not breathing: 10/12 breaths/min for adult, 12-20/min for infant or child. Never begin CPR or use an AED on a responsive patient. MNEMONIC (Doesn't get everything but) Peanut Butter TCC = Pulse, Bleeding, Temp, Color, Condition